AMS Final Study Guide PDF

Cardiovascular and Pulmonary APTA: Minimum required skills of entry-level PT graduates Must be able to recognize ○ General Health Condition Fatigue, Malaise Numbness/paresthesia Fever/chills/sweats Nausea/vomiting...

Cardiovascular and Pulmonary APTA: Minimum required skills of entry-level PT graduates Must be able to recognize ○ General Health Condition Fatigue, Malaise Numbness/paresthesia Fever/chills/sweats Nausea/vomiting Weakness Dizziness/lightheadedness Unexplained weight change Mentation/cognition ○ Cardiovascular System Dyspnea Orthopnea- discomfort when lying supine, difficulty breathing in supine, pain in chest Peripheral edema, LE swelling Palpitations Pain/sweats Cough Syncope ○ Pulmonary System Dyspnea Onset of cough Stridor a high-pitched, abnormal breathing sound that indicates a partial or complete blockage in the upper airway Change in cough Sputum Wheezing Hemoptysis - coughing up blood Clubbing of nails ○ Must be able to perform Screening (check for potential problems) Conduct a systems review Blood pressure, Heart rate, Respiratory rate Edema Read a single lead EKG Examination (tests & measures of potential problems) Blood pressure Heart rate / rhythm Respiratory rate / pattern / quality Breath sounds – normal/abnormal  Signs/symptoms of hypoxia Pulse oximetry ○ Nails can show signs of hypoxia Peripheral circulation (DVT, venous stasis, lymphedema) Aerobic capacity tests Response to exercise ○ Blood pressure in response to exercise Musculoskeletal (MSK) physical therapy (PT) 90% of MSK PTs do not routinely screen HR and/or BP during exercise Lack of perceived importance ○ No 1 reason why pts did not screen Lack of clinic/department policy Limited available time Equipment not available Not important for “my” patient population Lack of confidence in ability/competency Not certain what to do with the information How often do MSK PTs check HR? ○ 38% = “never” ○ 80% = “less than ½ the time” ○ 6% = “always” How often do MSK PTs check BP? ○ 43% = “never” ○ 83% = “less than ½ the time” ○ 4.4% = “always” 2019 physical therapy survey – screen HR and BP Only 10-15% of PTs in direct access are screening for BP and HR 51.38% know >50% of caseload has diagnosed CVD and/or moderate-high risk factors for CVD 69% of MSK PTs will encounter a patient with a moderate-high risk factor for cardiovascular disease a minimum of 2x/week 55% of MSK patients are unaware of having high blood pressure 30% of MSK patients have “masked hypertension” ○ Hypertension that does not always show up in blood pressure screening 41% of MSK patients with masked hypertension demonstrate exaggerated BP response to exercise and/or physical activity Masked hypertension is associated with a 2-fold increase in cardiovascular and pulmonary problems. High BP is the leading risk factor for CVD ○ Other high risk factors for CVD Smoking Diabetes  Dyslipidemia/hypercholesterolemia Obesity Physical inactivity/low fitness Unhealthy diet Family history Male sex Obstructive sleep apnea Psychological stress Blood Pressure Positive correlation between: ○ Increased systolic BP and CVD ○ Increased diastolic BP and CVD ○ i.e., the higher the pressure, the greater the risk Recommendations for outpatient MSK PT: ○ 1 stethoscope per therapist ○ 1 BP cuff for every 2 therapists ○ 1 small and 1 large BP cuff per clinic ○ 1 child BP cuff if there is ever a patient 10mmHg SBP with workload Absolute indication to terminate exercise Dizziness, nausea, faintness, blurring vision, hearing difficulties, abnormal fatigue Heart Rate/Rhythm Apical pulse between rib 4 and 5 Apex pulse, most accurate assessment of heart rate Respiratory Rate / Pattern / Quality Pattern Quality ○ Apnea: absence of spontaneous breathing, often occurs during sleep ○ Bradypnea: abnormal breathing pattern characterized by respiratory rate that is < 12 breaths per minute ○ Dyspnea: SOB, difficult breathing as perceived by patient ○ Eupnea: normal relaxed breathing ○ Orthopnea: difficulty breathing while lying down ○ Tachypnea: abnormal breathing pattern characterized by respiratory rate that is > 20 breaths per minute ○ Kussmaul: medical emergency characterized by abnormal breathing: hyperpnea ( deep, rapid), tachypnea and labored breathing that indicates the body is too acidic A type of hyperventilation that occurs when the body increases its breathing rate and depth to expel carbon dioxide and reduce blood acidity ○ Cheyne stokes: gradual increase and decrease of respirations with periods of apnea pattern of breathing that alternates between deep, rapid breathing and shallow breathing, followed by a pause Breathing becomes progressively deeper and sometimes faster, then gradually decreases until breathing stops temporarily Breath Sounds  Lung wheeze Rhonchi crackles/rales stridor Pleural friction sounds rub Location Most lung Larger Lung bases Partial Most lung spaces best heard spaces airways of obstruction of lungs - Trachea and trachea or upper airways bronchus Sounds like High Resemble -Bubbling, -May resemble pitched snoring, popping, or a wheeze-like -Creaking of whistling gurgling, or clicking noises sound but is leather (musical rattling Fluid in the less “musical” -Squeaking of sound) -Due to airways -Harsh, rubber shoe on Narrowed mucus turbulent, wet surface or blocked buildup in crowing sound -Does not change airways airway and after coughing may disappear after coughing Happens exhalation -Exhalation -Inhalation -Inhalation - Both inhalation/ most often -But can occur AND exhalation during with exhalation Causes Asthma, Asthma, CF, Pneumonia, Infections, Inflammation of bronchitis, COPD interstitial lung foreign pleural tissue COPD, disease, PE, objects, toxins, lining: pneumonia, pneumonia, atelectasis, inflammation, lung cancer, PE, CF, CHF, CHF, asthma, smoke, trauma TB, rib fracture allergies bronchiectasis Rhonchi- ronnie from jersey shore is large→ large airways, large men snore, rude men gurgle their drinks, and they like to rattle people up Signs / Symptoms of Hypoxia Restlessness ○ commonly an early sign Rapid breathing (tachypnea) ○ indicates respiratory distress Shortness of breath (dyspnea) Changes in skin color Confusion, Anxiety  Noisy breathing Flaring of nostrils, Pursed-lip breathing Pulse oximetry normal is 95-100%, if under 92→ REFER Peripheral Circulation Venous insufficiency ○ Stage 1: spider veins ○ Stage 2: reticular varicose veins ○ Stage 3: venous nodes ○ Stage 4: chronic venous insufficiency ○ Stage 5: trophic ulcers or varicose eczema Lymphedema Deep Vein Thrombosis ○ Lower Extremity DVT (Wells CPR)- MUST KNOW Clinical characteristics score Active cancer (treatment ongoing, within previous 6 months, or palliative) +1 Paralysis, paresis, or recent plaster immobilization of the LE +1 Recently bedridden >3 days or major surgery within 12 weeks requiring general or regional +1 anesthesia Localized tenderness along the distribution of the deep venous system +1 Entire leg swelling +1 Calf swelling 3cm larger than asymptomatic side (measured 10cm below tibial tuberosity) +1 Pitting edema confined to the symptomatic leg +1 Collateral superficial veins (non-varicose) +1 Alternative diagnosis as plausible as a DVT -2 0, -1, or -2 = low risk (unlikely) 1-2 = moderate risk >3 = high risk (likely) Upper Extremity DVT (Constans score) Clinical characteristic score  Localized UE pain +1 Central venous catheter or pacemaker +1 Unilateral UE edema +1 Alternative diagnosis as plausible as a DVT -1 0 or -1 = low risk - unlikely 1= moderate risk > 2 = high risk (likely) Pulmonary Embolism (3 classifications) - will not be tested, but good to be familiar with it Three-level Wells score (Sensitivity 84%, Specificity 58%) Criteria Points Previous PE or DVT +1.5 HR > 100 bpm +1.5 Recent surgery or immobilization +1.5 Clinical signs of DVT +3.0 An alternative diagnosis less likely than PE +3.0 Haemoptysis +1.0 Cancer +1.0 Patients with score of 0-1 are low risk, 2-6 are intermediate risk; and > or equal to 7 is high risk Two-level Wells score (Sensitivity 80%, Specificity 60%) ○ Same as three wells except clinical probability (2 levels) is different PE unlikely: 0-4 PE likely: > 4 Advanced Cardiovascular Medical Screening Guidelines for physician referral Vital signs ○ Persistent fall/rise of BP ○ BP elevation in any woman taking BCP ○ Pulse amplitude fades with inspiration or strengthens with expiration  Pulse amplitude reflects the amount of blood ejected by the heart with each beat, also known as the stroke volume. ○ Pulse increase over 20 BPM lasting more than 3 minutes after rest or changing positions ○ Difference of pulse pressure > 40 mmhg Pulse pressure is the difference between systolic and diastolic blood pressure ○ Persistent low grade or high grade fever associated with constitutional symptoms (sweats) ○ Any unexplained fever without other systemic symptoms (corticosteroids) Cardiac ○ > 3 SLNG (sublingual nitroglycerin) to gain angina relief ○ Angina increases after stimulus removed (cold, stress, exertion) ○ Changes in pattern of angina ○ Abnormally severe Chest Pain ○ Anginal pain radiates to jaw/left arm ○ Upper back feels abnormally cool, sweaty, or moist to touch ○ Client has doubts about condition ○ Palpitations h/o of unexplained sudden death in family > 6 episodes of palpitation in 1 minute or lasting for hours in association with pain, SOB, fainting, or severe lightheadedness ○ Neurologically unstable as result of CVA, head trauma, SCI, or other CNS insult - period of instability = new arrhythmias ○ Client cannot climb 1 flight of stairs without feeling moderately to severely winded ○ awakens at night or experiences SOB when lying down ○ Known cardiac involvement - develops progressively worse dyspnea ○ Fainting (syncope) without any warning signs/period of lightheadedness, dizziness, or nausea (think heart valve or arrhythmia or circulatory problems) Pulmonary ○ Shoulder pain aggravated by shoulder movements (clients hold breath/valsalva maneuver and reassess symptoms - any reduction or elimination of symptoms suggests CP source) ○ Shoulder pain aggravated by supine position (pain worse when lying down and improves when sitting up or leaning forward- pleuritic) ○ Shoulder or chest pain that subsidies with autosplinting (lying on painful side) ○ Client with asthma signs of asthma or abnormal bronchial activity during exercise ○ Weak and rapid pulse accompanied with fall in BP (PTX) ○ Presence of associated signs and symptoms, persistent cough, dyspnea (rest/exertional), or constitutional symptoms Video Notes: ○ Belching - anginal equivalent (heart sits on diaphragm and stomach underneath) ○ Diaphoresis - abnormal sweating when they're shouldn't be sweating  Something central going on Sweating not matching up to workload ○ Dyspnea - anginal equivalent ○ Nausea and vomiting - heart rests on diaphragm which sits on stomach ○ Indigestion, right coronary artery can be involved ○ Back and groin pain - thoracic abdominal aneurysm, aortic aneurysm ○ Sleep apnea has high correlation with high BP ○ Clear sputum when coughing- atelectasis - need to move them and get them up ○ Yellow sputum- infection ○ White to clear sputum in cough→ atelectasis→ keep them moving ○ Blurred vision? - blood flow; multiple changes in glasses prescriptions in the last year→ yellow flag ○ Headache, change in mentation, slurred speech→ TIA, CVA Why should we screen? Heart disease 1 in every 4 deaths ⅓ adults of high blood pressure Prevalence same for men and women, but in older age, women take over 80+ increased prevalence of heart disease Stroke ○ 35% happen in people < 65 years ○ 10% of strokes < 45 ○ ⅕ women in US will have a stroke ○ Risks HBP Migraines Autoimmune disease Clotting disorder Take HRT - hormone replacement therapy Birth control pills - estrogen Pregnancy Frequency and adverse consequences of clinically unrecognized and asymptomatic atrial fibrillation particularly in older adults Coagulation, mentation, medication Silent MIs account for almost 50% of incident MIs Review of Systems GI Part 1 Screening for Gastrointestinal causes of chest pain Broad range of referred pain patterns that come from stomach ○ Embryologic development ​Chest and upper abdominal contents made of same emby tissue anterior/midline abdominal pain  Women have nontraditional pain patterns with visceral issues Any type of organ system could be abdominal pain ○ Multisegmental innervation Stomach innervated by thoracic pain system Poor receptor density and a lot of overlap between visceral structures Can feel pain in thoracic spine from a stomach you can experience pain in multiple sites at the same time due to multi segmental innervation ○ Direct pressure/shared pathway underneath diaphragm: liver, stomach, gallbladder, pancreas spleen→ any of those structures that become distended, cystic, bleeding can irritate diaphragm and cause shoulder pain Causes: inflammation, distention, necrosis (ischemic) Commonly reported symptoms ○ Emesis - blood in vomit , issue with upper gi bleed ○ Melena - lower GI bleed or Gi bleed higher up by the time blood passes through small intestine through large intestine, blood is starting to clot and turn dark ○ PMHx: → higher risk factors Alcoholism Cirrhosis Esophageal varices Esophageal cancer Peptic ulcers Long term use of steroids Referred pain from the esophagus ○ Innervation: vagus nerve and spinal nerves (from segments T1 to T10) ○ If someone has irritation or ulcer at esophagus in one location like T5 then patient may just report a band of pain that runs across chest or throat ○ If multiple areas of problems in esophagus→ pain localized in back or thoracic spine ○ Isolated thoracic spine pain→ rule out ○ Esophageal pain has many patterns. burning, gripping, pressing, boring, or stabbing. GERD- movement of gastric acid back up into esophagus More gastric acid produced after eating and issue with valves at level where → pain in esophagus area where tube meets stomach It may be associated with a foul taste, morning pain, worsening pain after a meal, and epigastric tenderness/ near xiphoid junction Severe esophagitis may refer to pain in the anterior chest. Depends on where it is in the level of the viscera Esophageal problems tend to be felt mainly in the throat or epigastrium.  On occasion, it can radiate to the neck, back, or upper arms—all of which may equally apply to cardiac pain. The stomach The pain of a peptic ulcer occasionally occurs only in the back between the 8th and 10th thoracic vertebrae. Innervation: Innervation of the stomach celiac plexus from spinal cord segments T6 through T9. Epigastric pain can come from stomach too Epigastric pain Substernal or upper abdominal discomfort If stomach issue→ epigastric or substernal Long standing duodenal ulcers→refer posteriorly thoracic pain Acute Gastric ulcers ○ Occasionally refer to the anterior chest and can migrate ○ Anything that starts in the front and moves to the back→ rule out Clinical presentation: ○ Nausea ○ Vomiting ○ Blood in stools ○ Pain with swallowing or associated with meals If food alleviates symptoms; food can serve as buffer for pH ○ Heartburn ○ Jaundice Gastroesophageal reflux disease Defined as symptoms or mucosal damage (esophagitis) resulting from the exposure of the distal esophagus to refluxed gastric contents. Clinical presentation: ○ Gripping, squeezing, burning in chest or back ○ Use of antacids or food alleviates pain Eating low ph/more acidic food can make it worse ○ Sometimes lying flat can worsen symptoms Usually with MSK symptoms, lying flat can help Worse with recumbency ○ Ulcer pain is not produced by effort; usually no aggravating or easing factors unless related to food ○ Chest pain Lasts longer than angina pectoris Angina Precipitated by exercise GERD Not related to effort or exertion or exercise ○ PT will not be able to provoke symptoms on examination  No long lasting effects of PT Can Assess TrP Constant afferent nociceptive input from stomach that goes to thoracic spine→ may have some trigger points on back that reproduce patient symptoms NSAIDs Antiinflammatory drugs Nonselective COX inhibitors (examples) ○ Lodine ○ Indocin ○ Motrin ○ Advil ○ Feldene ○ Relafen ○ All of these can adversely impact Selective COX-2 inhibitors ○ Celecoxib (Celebrex) - predominant on market ○ Valdecoxib (Bextra) ○ Rofecoxib (Vioxx) ○ Better than taking nonselective Phospholipase breaks down into arachidonic acid ○ Can be made into cox 1 and cox 2 ○ Cox 1 = protective for kidneys and stomach Helps promote healthy mucosal layers to block acid or irritation of kidneys Produce prostaglandins (PGI2, PGE2) that protect the visceral structures If we take meds that block cox 1 like an NSAID→ kidney issues or peptic ulcer disease Can Protect the gastric mucosa or serve as inflammatory instigator Inhibit gastric acid secretion Maintain blood flow to gastric mucosa ○ COX2 Creates joint pain and inflammation Pro inflammatory mediators Involved in patients with OA Cox 2 inhibitors blocked COX2 from creating inflammation and pain, but allowed COX1 to do its function NSAID induced GI complications Both cox 1 and 2 inhibitors Adverse Reactions: More than 100,000 hospitalizations annually Estimated $2 billion in hospital costs  16,500 deaths per year Kehr’s sign Lots of patients take antiinflammatories way too often and for long periods of time without a lot of oversight from MD Any patient that takes NSAIDs→ always ask if they have any chest or stomach pain/upset Older patients (>70) and people taking corticosteroids much higher risk of developing peptic ulcers Clinical Manifestations of gastric ulcer Sometimes they can be Clinically silent→ Large proportion of people with ulcers may have no signs or symptoms Abdominal/thoracic spine pain Night pain ○ Particularly lying down or flat Indigestion/heartburn Nausea Pain relief with food ingestion Melena Fatigue Screening Questions for patients with abdominal pain that could be MSK origin two specific clusters of questions to be used in identifying patients with abdominal pain that is musculoskeletal in origin: Cluster 1 ○ Does coughing, sneezing, or taking a deep breath make your pain feel worse? (Yes) ○ Do activities such as bending, sitting, lifting, twisting, or turning over in bed make your pain feel worse? (Yes) Can be ribs or thoracic spine but could also be pulmonary PAIVM, active range of motion limited ○ Has there been any change in your bowel habit since the start of your symptoms? (No) ○ If they say yes to first two and no to last one→ high probability that MSK origin Cluster 2 ○ Does eating certain foods make your pain feel worse? (No) ○ Has your weight changed since your symptoms started? (No) ○ If both answered no→ in addition to corresponding responses to the questions in Cluster 1, there is an even greater probability that abdominal pain is musculoskeletal in origin. Large and small intestines  Large Intestine: ○ Embryological: midline ○ Multisegmental: sympathetic: T10-L2 parasympathetic (vagus nerve): S2-4 ○ Several referral patterns ○ Can refer to either upper lumbar or lower thoracic; rare for someone to have high lumbar pain except for injury ○ Mid to lower abdomen compared to stomach pain which is more midline Small Intestine: ○ Embryological: midline ○ Multisegmental: T9-11 ○ Lower thoracic pain - think small intestine and kidneys Colorectal Cancer Colorectal cancer is the third most common cancer Always screen for; Usually more in men Risk factors include middle-older age, a diet rich in fat and cholesterol, inflammatory bowel disease (especially ulcerative colitis)- can irritate lining and cause growth in tissue), and genetic predisposition. The most common metastatic presentation of colon cancer is in the thoracic spine and rib cage. ○ One of most common places for cancer to metastasize is the thoracic spine ○ If older individual has thoracic pain→ sus and make sure to screen The overall 5-year survival rate from colon cancer is approximately 60%, and nearly 60,000 people die of the disease each year in the United States. Red flags for colon cancer ○ age greater than 50 years; ○ history of colon cancer in an immediate family member; ○ bowel disturbances (e.g., rectal bleeding or black stools) ○ unexplained weight loss ○ back or pelvic pain that is unchanged by positions or movement. Large intestine obstruction Volvulus ○ abnormal twisting of a segment of intestine around itself→ produces a closed loop of bowel with a pinched base, leading to intestinal obstruction or blockage of bowel ○ a medical emergency  ○ In Western countries, volvulus is most common among people over age 65, and these patients often have a history of chronic (long-lasting) constipation. ○ Abdominal palpation is appropriate for this patient→ Diverticular disease ○ In the large bowel, diverticula are small, balloon-shaped pouches that protrude from the wall of the intestine. ○ If diverticula become infected→diverticulitis Small bowel obstruction Can be caused by ○ Adhesions: areas of tough, fibrous connective tissue that are a type of scar. ○ Adhesions develop on the outside of injured intestine or pelvic organs as they heal after surgery or infection. Can be caused by Hernia — If there is a structural weakness in the muscles and fibers that are part of the wall of the abdomen, a portion of the small intestine may protrude through this weakened area, and appear as a lump under the skin Bowel obstructions Symptoms of small-bowel obstruction can include: ○ Cramping abdominal pain, generally coming in intense waves that strike at intervals of five to 15 minutes and sometimes center either on the navel or between the navel and rib cage ○ (Pain that becomes constant may be a symptom of bowel strangulation) ○ Pain comes in waves- intense for 1 minute then calms down ○ Nausea and vomiting ○ No gas passing through the rectum ○ A bloated abdomen, sometimes with abdominal tenderness ○ Rapid pulse and rapid breathing during episodes of cramps can occur Symptoms of large-bowel obstruction can include: ○ A bloated abdomen ○ Abdominal pain, which can be either vague and mild, or sharp and severe, depending on the cause of the obstruction ○ Constipation at the time of obstruction, and possibly intermittent bouts of constipation for several months beforehand ○ If a colon tumor is the cause of the problem, a history of rectal bleeding - different from hemmys- bright red blood on tissue Rectal bleeding - typically streaks of blood within bowel itself ○ Diarrhea resulting from liquid stool leaking around a partial obstruction ○ If pt has these symptoms for more than 3-4 days→ REFER Review of Systems Gastrointestinal  Difficulty with swallowing nausea/heartburn Vomiting Specific food intolerance Constipation Diarrhea Change in color of stools Rectal bleeding Jaundiced History of liver or gallbladder problems Guidelines for immediate physician referral: Gastrointestinal Associated nausea/vomiting, dysphagia Epigastric pain Change in bowel color-melena Shoulder pain relieved with antacids or pain in shoulder relieved after eating History of previous ulcer or use of NSAIDs Cannot reproduce signs and symptoms of pain Guidelines for abdominal palpation Observation: ○ Skin condition Rashes/striae Striae- red streaks/stretch marks, flesh colored-normal- could be indication of rapid weight loss after rapid weight gain purple hue: possible Cushing syndrome - excessive cortisol Purple hue around umbilicus-Cullen’s sign ○ Surface contour ○ Position of umbilicus ○ Look at patient From a seated and standing position Look for general distention Local bulges - could be (hernia) Look for scarring Weight in abdomen should be equally distributed and should not be hard Inspection ○ Make note of the following: Scars Color of the skin Bluish/purple discoloration around umbilicus (Cullen’s sign) - can be sign of internal bleeding - edward cullens lips are purple/blue and he is emo- bleeds internally  or along the lower abdomen (Grey Turner’s sign) = retroperitoneal bleed ○ Inspections within the quadrants ○ Look at quadrant as if you are the patient themselves ○ RUQ: liver and gallbladder ○ LUQ: stomach, pancreas, spleen ○ RLQ: appendix, ovaries, uterus, large and small intestine Auscultation ○ Listen before you palpate first ○ Auscultate the four abdominal quadrants Should be done first before palpation or percussion to avoid altering bowel sounds Expect to hear clicks, rumblings, and gurgling sounds every few seconds If patient hasn't eaten in a while→ could be quiet ○ Absence of sounds/few sounds in any or all of the quadrants is a red flag Especially in lower quadrants Especially if increased tenderness, or swelling Ileus Pseudo-obstruction; the intestines temporarily stop working properly→ no bowel sounds Opioids can cause slowing of peristalsis within colon colon becomes lazy - food material gets stuck within intestines and doesn't move Most common in the older adult with multiple risk factors Recent abdominal, back, or pelvic surgery Use of narcotics Palpation ○ WE ARE NOT DIAGNOSING ○ Palpation of the four abdominal quadrants ○ Assess temperature changes ○ Tenderness Firm but light pressures, circular then deeper pressure Broad, flat contact ○ Most viscera are not palpable unless enlarged Note masses, m. guarding, referred pain ○ Palpation is contraindicated in anyone with a suspected AAA, appendicitis, or organ transplantation Can cause aneurysm or appendix to rupture ○ Use the back of your hand, all quadrants should feel equal Procedure for abdominal palpation ○ Abdominal palpation: Begin with light touch Move fingers in a circular direction  Observe abdominal rigidity with breathing pattern Strongly contracted during inspiration and less contracted with expiration=voluntary contraction Equal amounts of contraction with inspiration/expiration=possible underlying abdominal problem ○ Start from quadrant furthest away from where you think pain is Screening for the Spleen, Hepatic, and Biliary Disease Spleen Lies just behind and slightly lateral to stomach Site of RBC production and role in immune system Removes old RBC and holds a reserve of blood in the event of Hemorrhagic shock - losing blood rapidly Synthesizes antibodies and removes bacteria ○ Helps immune system Produces monocytes=macrophage Referred pain from the spleen ○ The location of the spleen means that injury to this organ can cause pain in the upper-left part of the abdomen. ○ LUQ ○ Can cause midline upper abdominal pain or ipsilateral shoulder via pressure on diaphragm or through multisegmental pathways ○ However, after a rupture, pain can occur in other locations, such as the left chest wall and shoulder. ○ Pain felt in the left shoulder as a result of a ruptured spleen is known as Kehr's sign. Bruised or red area ○ Bottom picture = young male tackled in football with main complaint of L shoulder pain→ positive kehrs sign Splenomegaly: Signs and symptoms An enlarged spleen may cause: No symptoms in some cases Or can have Pain or fullness in the left upper abdomen that may spread to the left shoulder ○ Spleen is pressing on stomach Feeling full without eating or after eating only a small amount from the enlarged spleen pressing on your stomach Anemia Fatigue Frequent infections  ○ Spleen cant perform its immune functions Easy bleeding Splenomegaly ○ A number of infections and diseases may cause an enlarged spleen. ○ The enlargement of the spleen may be temporary, depending on treatment. Contributing factors include: Viral infections, such as mononucleosis→ spleen becomes enlarged and can become vulnerable to rupture Bacterial infections, such as syphilis or an infection of your heart's inner lining (endocarditis) Parasitic infections, such as malaria - people traveling out of country Cirrhosis and other diseases affecting the liver Various types of hemolytic anemia — a condition characterized by early destruction of red blood cells Blood cancers, such as leukemia and myeloproliferative neoplasms, and lymphomas, such as Hodgkin's disease Metabolic disorders Niemann-Pick disease a rare metabolic genetic disorder that causes a buildup of fat and cholesterol in cells Gaucher's disease: rare, inherited metabolic disorder that causes fatty substances to build up in the body's organs and tissues Pressure on the veins in the spleen or liver or a blood clot in these veins Refer when Left upper abdominal pain especially with palpation and the presence of high risk factors such as: ○ Children and young adults with infections, such as mononucleosis/mono ○ People who have Gaucher's disease, Niemann-Pick disease, and several other inherited metabolic disorders affecting the liver and spleen ○ People who live in or travel to areas where malaria is common ○ Pain in your left upper abdomen, especially if it's severe or the pain gets worse when you take a deep breath. ○ Increasing left shoulder pain or left abdomen when taking deep breath Complications: ○ Infection. An enlarged spleen can reduce the number of healthy red blood cells, platelets and white cells in your bloodstream, leading to more frequent infections. ○ Anemia and increased bleeding also are possible. ○ Ruptured spleen. Even healthy spleens are soft and easily damaged, especially in car crashes. ○ The possibility of rupture is much greater when your spleen is enlarged. A ruptured spleen can cause life-threatening bleeding into your abdominal cavity. ○ A minor trauma to lateral aspect of trunk can cause life threatening injury to spleen Palpation of the spleen Patient is supine Clinician: stands to the right of the patient Reach across the patient with your left hand and place other hand under left costovertebral angle Lift spleen anteriorly toward the abdominal wall Place fingertips below left costal margin and press toward spleen Have patient take deep breath If you palpate and left shoulder pain→ Kehr’s sign + Place non palpating hand slightly below rib and lateral to chest wall Musculoskeletal pain associated with hepatic/biliary systems Referred pain to: ○ Thoracic spine ○ Right shoulder ○ Right upper trapezius ○ Right subscapular pain Emby development - midline anteriorly Multisegmental Pain to shoulder - direct pressure/shared pathway Gall bladder can cause pain to inferior angle of right scapula The liver Sympathetic cord level: T7-9: greater splanchnic nerve ○ Could experience mid thoracic pain ○ Multisegmental pathway; patient may only perceive mid thoracic pain Sensory: afferent impulse through the phrenic nerve C4-5 ○ Shares sensory afferent through phrenic nerve Ligaments of the liver attach to the diaphragm ○ Pts with enlargement of right lobe that pull on ligaments can give perception of rib pain as one of the ligaments attaches to ribs 2 mechanisms how liver can refer pain: multisegmental and shared afferent pathway Liver and gallbladder Sympathetic biliary and hepatic fibers to cord via the splanchnic plexus in dorsal aspect of the spine  Most of the sympathetic fibers reach the cord through the right splanchnic nerves Synapse with adjacent phrenic nerves innervating the diaphragm→right shoulder pain Afferent input to celiac ganglion→ greater splanchnic nerves into levels of T6-T9 for liver Afferent input from liver, mostly from right side of cord ○ Pts can perceive pain centrally or to right side If sensory→ can go to right shoulder; sensory innervation for liver is phrenic nerve → can cause C4-C5 pain Viscero-somatic referred pain-multisegmental innervation Visceral input to SC is misinterpreted as a MSK problem Gallbladder has most of its innervation from the right side of the cervical ganglia to the splanchnic nerves right sided symptoms Most of gallbladder and liver has its innervation from right side Although the innervation from the gallbladder is bilateral to the cord, most of the biliary fibers synapse with adjacent phrenic nerve fibers innervating the diaphragm and right shoulder pain Referred pain from the gallbladder-embryologic development The heart and gallbladder are derived from the same embryologic tissue Liver and gallbladder can cause central pain and refer to the chest Liver Disease If patient with hx of liver issues that come in with shoulder, thoracic, or rib pain→ make sure to SCREEN Look at current or past medical history Can be acute/chronic, mild/severe, reversible/irreversible condition Acute: viral hepatitis- could be from hep type A, subclinical Cirrhosis: irreversible Fatigue Loss of appetite Nausea General body ache/flu-like symptoms Diseases of the liver ○ Major contributions: Hepatitis Drug-induced hepatitis Ingestion of hepatotoxins ○ Physical examination: Look for-right shoulder pain, active tremors, paresthesias, skin/nail bed changes  Liver is huge→ it comes down almost to 5th rib on the right and left sides and crosses midline to the left side of body Visual inspection for liver disorders Skin changes Itching Jaundice Spider angiomas ○ Branched dilations of superficial capillaries ○ Arteriole dilated capillaries that look like spideys ○ Increased estrogen levels normally detoxified by the liver Palmer erythema ○ Redness ○ AV anastomoses ○ May complain of tingling/throbbing Liver helps break down certain chemicals and if they don't do it well→ higher levels of circulating chemicals like glutamate causing irritation to nerves, can cause non dermatomal tingling within body Nails of Terry ○ Looks like white part of base of nail followed by red of distal 3rd of nail bed ○ Terry from shameless is white but is hot headed and drinks a lot of liquor because he is shameless Effects of medications on liver function Hyperlipidemia: elevated serum cholesterol ○ Use of statins to reduce LDL ○ Typically when patients start statins, they will have 6 or 10 month check in to make sure their liver enzymes arent elevated ○ Statins can have big effects on liver ○ Side effects: myopathy, myalgia and joint pain Zocor, Lipitor, Crestor, Lescol, Pravachol If detected early, can be reversible Events are dose dependent 5-18% of adverse rates reported Often patients noted their signs and symptoms occurred when they started statin drugs ○ Monitoring of serum liver enzymes and creatine kinase Indicators of muscle and liver impairment: AST, ALT, ALP creatine kinase Signs and symptoms of statin-induced myopathy  ○ Symptomatic myopathy (muscle soreness, weakness, dyspnea), Myositis-can have elevated CPK- creatine phosphokinase Can have Weakness in several muscle groups ○ Unexplained fever ○ Nausea/vomiting ○ S/S of liver impairment Dark urine Asterixis Bilateral CTS Palmar erythema/spider angiomas Nail bed changes ascites Clinical signs and symptoms of liver disease Confusion Sleep disturbance Muscle tremors Look for bilateral tingling/numbness ○ Could be metabolic problem ○ Usually think diabetes, but when bilateral→ can be metabolic or liver related Hyper-active reflexes Asterixis ○ Increased serum ammonia and urea levels→impairs peripheral nerve function ○ Bilateral CTS, tarsal tunnel ○ When liver not breaking down chemicals in body on normal basis→ ammonia can circulate → can cause neurotoxicity ○ Have patients extend their wrist→ you may see their fingers flap up and down→ often times and indication of liver disease Dark urine/light colored BM ○ Light colored stools and dark urine→ liver or gallbladder issue Ascites - hard abdominal swelling Diseases of the Liver Hepatic osteodystrophy- abnormal development of bone Etoh Pain in wrists and ankles Rhabdomyolysis - break down of protein within muscle ○ Urine will start looking brown red as myoglobin breaks down Bowing of femur - the picture Palpation of the liver Patient position: supine hook lying  Clinician: ○ Left hand under the right posterior thorax, parallel to and at the level of the last 2 ribs ○ Right hand on the RUQ over the midclavicular line ○ Fingers under the costal margins pointing toward the patient’s head ○ Have patient inhale while pressing inward and upward ○ Attempt to feel in inferior margin as it descends below the last rib ○ To palpate liver→ find xiphoid and lateral most rib and go ⅔ the way with both hands to find liver, same for gallbladder but go ⅓ ○ One hand on top of the other and point towards ipsilateral shoulder Find midclavicular line→ come straight down The normal liver will feel smooth, firm, even, and rubbery A palpable hard or lumpy edge warrants a physician referral. Gallbladder-same technique except fingertips are slightly more medial. Have fingers angled towards right shoulder and have them take a deep breath→ if that causes abdominal pain or reproduces mid thoracic/shoulder pain→ REFERRRRRRR Musculoskeletal manifestations of gallbladder disease Viscero-somatic referred pain ○ Can refer to thoracic spine and ribs Liver and gallbladder can cause a spasm of the rectus abdominis muscles above the umbilicus ○ GI disturbance affects motor reflexes in the anterior horn of SC at the involved level 10th rib pain ○ Right side, anteriorly ○ Ligaments from liver attach here; liver and gallbladder can cause right sided rib pain Itching (pruritus) ○ Gall bladder issues can lead to itching along rib or thoracic spine or shoulder from afferent nerves coming from injured or disease organ coming from spinal cord ○ Visceral and cutaneous fibers entering the SC at the same level Cholelithiasis/gallstones Formation of gallstones 5th leading cause of hospitalization among adults Accounts for 90% of gallbladder disease  Incidence increases with age ○ 40% over age 70 Usually more of an issue for older people Cholelithiasis: Risk Factors ○ Age ○ Women > men ○ Elevated estrogen levels Pregnancy Oral contraceptives Post-menopause ○ Obesity ○ High cholesterol diet ○ Diabetes ○ Liver disease Referred pain from the gallbladder ○ Cholecystitis ○ Gallstones can try to exit out cystic duct and get stuck and lodged→ bile produced in gallbladder cannot get out to aid in digestion→ can lead to infection or inflammation of gallbladder as fluid backs up ○ Normal flow of bile is interrupted Becomes distended and ischemic ○ Leads to infection or inflammation of the gallbladder Clinical signs and symptoms of cholecystitis ○ Attacks of epigastric pain ○ RUQ pain ○ Right scapula region ○ Worse after eating fatty meal Bile from gallbladder needed to break down fats ○ Usually constant pain ○ Nausea/vomiting ○ Fever and chills ○ Dark urine/jaundice=stone obstruction in a bile duct ○ Mid thoracic area ○ Shoulder from direct pressure/shared pathway Palpation of the gallbladder The gallbladder is occasionally palpable below the right costal margin in the midclavicular line. If enlarged, it will be felt as a soft, rounded mass which, like the liver, moves down on inspiration  Rolling the patient 45 degrees to the left makes the gallbladder more visible and facilitates its palpation. Similar to liver, but we are mid ⅓ under the ribs Anytime you have pt with primary problem in thoracic spine→ always make sure to rule out visceral or mets Review of Systems: Gastrointestinal and Hepatic/Biliary System Screening for Gastrointestinal causes of pain referral Broad range of referred pain patterns ○ Embryologic development ○ Multisegmental innervation ○ Direct pressure/shared pathway R shoulder pain from liver issue Commonly reported symptoms Abdominal pain GI bleeding (emesis, melena) Sx affected by food ○ Gastric issues Constipation ○ Dehydration can cause lower abdominal bloating or low back pain (kidneys?) Fecal incontinence ○ Cauda equina, saddle anesthesia - changes in sensation Dysphagia/Odynophagia Epigastric pain (radiation to the back) ○ Band of pain across Early satiety, weight loss ○ Don't eat a whole lot but get really full very easily Diarrhea Arthralgias ○ Migratory joint pain→ something of concern, may need to go back and see PCP The spleen Lives just on top and behind stomach, stomach is in LUQ All afferent input comes from celiac ganglia from T12- L1 Spleen can get referral to mid lower thoracic spine and lower abdomen Abdominal wall Clinical findings that differentiate abdominal intra visceral pain from abdominal wall pain Clinical finding Intra abdominal visceral Abdominal wall pain pain (organ issue) (muscle issue) Advanced imaging findings Often positive Unusually remarkable Carnett test negative positive Constitutional symptoms Anorexia, chills, fever, weight Typically absent loss GI or genitourinary symptoms Altered bowel habits, dysuria, Typically absent frequent urination, GI bleeding, jaundice, nausea, vaginal bleeding or discharge, vomiting Laboratory findings Elevated white blood cell Usually within normal limits count, inflammatory markers, or serum lactate level Pain characteristics aggravated/relieved by eating Unrelated to meals or bowel or defecation; peristaltic pain function; constant or fluctuating, non peristaltic Sex predominance none females  Tender spot Location depends on Clearly identifiable superficial underlying pathology; tender area < 2 cm, typically relatively vague near the rectus abdominis Algorithm for evaluation of abdominal wall pain - don't really need to know but should understand Carnetts is a physical exam that helps determine if abdominal pain originates from the abdominal wall or the abdominal organs: The patient lies down and points to the painful area. The clinician then presses on the most painful spot with a finger while the patient tenses their abdominal muscles by raising their trunk or flexing their hip. If the pain worsens, the Carnett sign is positive, indicating that the pain is more likely to be from the abdominal wall. What a negative result means If the pain decreases, the Carnett sign is negative, indicating that the pain is more likely to be from the abdominal organs. If someone has abdominal pain→Positive carnets? → ○ Not positive→ evaluate for intra ab visceral disease ○ Positive → do findings suggest intra abdominal visceral disease→ yes? → evaluate for visceral diseases ○ Positive→ do findings suggest intra abdominal visceral disease→ no? → ○ look for constitutional symptoms→ if sounds visceral→ Evaluate and refer for visceral disease If no constitutional symptoms→ other types of causes Rheumatic disease: physical therapy Screening & management What are rheumatic diseases? Rheumatism: “any of various conditions characterized by inflammation or pain in muscles, joints, or fibrous tissue” Rheumatic Diagnosis Vs. Musculoskeletal Injury ○ 4 cardinal signs of Inflammation Rubor = red Dolor = pain Tumor = swelling (tumor = expansion = swelling) Calor = heat (calories produce heat) ○ These are also commonly seen in MSK injuries… how do we differentiate them Rheumatic diseases: WHAT IS UNIQUE Etiology: ○ Auto-immune diseases ○ Chronic & progressive in nature ○ Characterized by periods of flare ups and remission  ○ As disease progresses→usually increases in severity or debilitating ○ Signs/Sxs: Pain in joints, muscles, bones, swelling, stiffness Systemic Signs/Sxs: Malaise, fatigue, chills, fever Testing can be done for these specific diseases: ○ Blood tests: general inflammatory markers (CRP-cero reactive protein, ESR) ○ CRP: protein produced by the liver that indicates the presence of inflammation in the body ○ Specific Ab tests (Rh factor-rheumatoid factor, antinuclear antibodies, anti-citrullinated antibodies) ○ Imaging: X-ray, MRI, US ○ Family Hx & Genetic Testing: (e.g., HLA-B27) HLA antigen haplotype-B27 = genetic marker found in high % of Ankylosing Spondylitis and could be in other ”spondyloarthritis” Dx (e.g., reactive arthritis/Reiter’s disease) What may lead you to suspect rheumatic disease? onset/moi & course: ○ Usually gradual/insidious onset, could be sudden (e.g., if triggered by food as in gout) ○ Some could be acute ○ Characterized by “flare-ups” & “remission” periods (or gradual worsening) Joint Or Muscle Pain, Stiffness, Swelling ○ Often Widespread: At multiple joints or muscles ○ often symmetric (bilateral) ○ Usually Not caused by acute MOI or trauma (and/or not ”reproducible” upon exam) Systemic Signs/Sxs Of Inflammation And Immune Response* ○ Red, Pain, Swelling, Heat ○ Elevated Inflammatory Markers (CRP, ESR) ○ Malaise, Fatigue, Chills, Fever *May Be The Most Important To Differentiate From A “Musculoskeletal” Cause!* Clinical Takeaways: Key Signs/Sxs Early ID/Referral of Rheumatic Disease is important to manage Medications, prevent joint destruction (usually irreversible once it occurs) and facilitate remission ○ Psoriatic Arthritis = rapid progression of Disease → so early Dx and Tx = very important ○ Need to differentiate between “Osteoarthritis” which is NOT a rheumatic disease Case #1: 43yo M /c R Toe Pain Subjective:  ○ Went out last night for 25th HS reunion, woke up in AM today with swollen, red toe, PWB - limping a little bit ○ MOI/Onset: …was drinking last night and thinks he ”jammed it” stepping off curb wrong ○ PMH: Had some pain in ankle last year, but went away on its own. No prior toe pain. ○ Signs/Sxs: R great toe is swollen, aching, and hurts to walk, throbs at rest, 2 – 6/10 Pain ○ Review of Systems & Screening HTN, DM, non-smoker ○ Prior Treatments/Providers/Imaging Direct access, no imaging, tried ice and tylenol ○ Denies numb/tingling/radicular signs and symptoms, no x-ray, has not seen a doctor Objective: ○ 1st toe: swollen, reduced AROM and PROM, painful in all directions, lumps in gait, calf raises w/ pain; antalgic gait - less weight through toe ○ Toe strength equal B, vibration test negative for fx, Ottawa Ankle Rules’ negative (no TTP at navicular, 5th styloid, med/lat malleoli) ○ Not point tender, pain w/ palpation at great toe and 1st MTP joint, negative varus/valgus tests at IP joint (pain but no laxity noted) Key Information: ○ Objective: didn't really find any issue to narrow down as suspected pain driver beyond general sprain for first great toe ○ No hx of pain there→ might indicates sprain more likely ○ A little relief from ice and tylenol→ more likely indicates MSK ○ We should highly suspect alternative cause for pain given other factors ○ Might have acute onset of gout Male, > 40 years old→ fits stereotype Mechanism of injury? - not necessarily sure it happened due to alcohol use ○ Pain at rest? - sus Clinical Decision? ○ We could refer right away to get more testing, or propose conservative physical therapy treatment ○ If he does not make improvement, we could refer How COMMON are Rheumatic Diseases? In context of other MSK stuff we will see LBP > Neck Pain > OA > Gout > CTS, Fibro > RA > “Spondyloarthropathies” Incidence = “Risk of getting Disease initially ” Prevalence = “Number of People in Population WITH the disease” (Can reduce prevalence by either: cure or death Prevalence = Incidence X Duration of Disease  OA more common than gout; Gout is one of the most common, 8 mill in US, RA, 1.3 million in the US Have a broad idea of how likely each are and how common they are Useful Terms & Definitions monoarticular - affects one joint oligoarticular - affects a few joints Polyarticular - affects many joints Dactylitis = swelling of an entire digit; not just pip, but PIP, IP, DIP Enthesitis = inflammation of “entheses” organ (where tendon/ligament inserts into bone) ○ May mimic insertional tendinopathies Spondylo- (G. “Spondylos” = a vertebrae) Arthro- (G. “arthron” = a joint) “Spondyloarthritis”: umbrella term referring to inflammatory conditions that affect both joints and attachment sites of tendons/ligaments (entheses) ○ Many diagnoses fall under this umbrella ○ ankylosing spondylitis, psoriatic arthritis, reactive arthritis, IBS associated arthritis Differential Dx: Rheumatic Dx ReA = Reactive Arthritis (Reiter’s Syndrome) IBD-SpA = IBS associated arthritis There are overlaps between these conditions Rheumatoid arthritis ○ MANY joints affected - polyarticular ○ Bilateral/Symmetric ○ Nodules, swelling ○ Joints: Usually smaller joints Fingers, hands, wrists PIPs, MCPs - more proximal joints ○ (less common DIPs) Psoriatic Arthritis (PsA) ○ A few joints affected; typically presents with psoriasis ○ Unilateral (usually) ○ Enthesitis present in 60-80% of patients (most common at: Achilles’ tendon, patellar tendon, quadriceps tendon, plantar fascia, supraspinatus tendon, med/lat epicondyles) ○ Dactylitis/sausage digit present in about 50% of patients ○ Nail Dystrophy = discolored or deformed nail bed (e.g., pitted nail bed) present in 66% of patients ○ Joints: DIPs Affected  (ALL joints of digit) Maybe spine Gout ○ One or a few joints ○ Unilateral (usually) ○ Joints: Great Toe (1st MTP) Ankles Knees Ankylosing Spondylitis (AS) ○ One or a few joints ○ Bilateral/Symmetric ○ X-ray/MRI (“Bamboo Spine”) ○ Joints: Spine (axial) Sacroiliitis (SI joints) Chart comparison of the rheumies Arthritis Charts Rheumatoid Arthritis Blood Tests: ○ +Anti-citrulline Abs (ACPAs) more sensitive and specific to Dx RA vs. rheumatoid factor Abs ACPA = Anti-citrullinated Protein Antibodies ○ Elevated CRP, ESR Treatments: ○ PT Treatment : AROM, Modalities, Protect Joints Guided Exercise can improve quality of life and muscle strength NO evidence that physical activity impacts inflammation in RA! ○ overexpression of TNF→Drugs that inhibit TNF ○ “non biologics” and “Biologics” such as TNF inhibitors RA Associated Syndromes: ○ Sjogren’s Syndrome = dry mouth, dry eyes ○ Felty Syndrome = splenomegaly, neutropenia RA Prognosis: ○ if Anti-citrulline Abs are present = Negative Prognosis ○ (more synovial fibrosis, joint damage) Notes: ○ Synovium is inflamed due to antibodies attaching to citrullinated proteins (ACPA = Anti-Citrullinated Peptide Antibodies)  ○ Antibodies attack synovium and lead to joint damage Psoriatic Arthritis Treatments: ○ EARLY pharmacological Treatment ○ (DMARDs), NSAIDS, corticosteroids Lab tests/imaging ○ X-Ray/MRI/US: Joint inflammation Imaging: shows NEW bone formation ( Vs. bone loss, demineralization in RA) vs RA - which is bone loss Majority will develop skin lesions before joint pain or inflammation- key in patients history Reiter’s Syndrome” (Reactive Arthritis) Signs/Sxs: ○ “Classic Triad”: 1. Conjunctivitis, 2. Urethritis, 3. Arthritis ○ (Patient “Can’t see, Can’t pee, and Can’t climb a tree” ) Inflammation and pain at three different sites.. Eyes, urethra, joints Treatments: ○ Antibiotics, NSAIDS, corticosteroids, joint splinting Dx of Reactive Arthritis can be difficult d/t (only about 1/3 pts have all 3 of “classic triad” sxs at onset) no single lab test, Dx based on clinical signs/sxs Ankylosing Spondylitis Treatments: ○ NSAIDs, DMARDs, Anti-TNF drugs ○ PT to treat impairments Progressive “ankylosing” or stiffness in joint leading to fusion of joint Ankylosing Spondylitis affects: SI joints > facet joints, costovertebral joints, intervertebral discs Can cause postural deformities (i.e., flexed/stooped over posture) *If 4/5 Positive answers (“YES”) =.95 sensitivity and.85 specificity for ankylosing spondylitis ○ 1. Morning stiffness? ○ 2. Improvement in discomfort with exercise but not rest? ○ 3. Onset of back pain before age 40yo ? ○ 4. Was onset slow/gradual? ○ 5. Has pain persisted for at least 3 months? Gout Demographics: ○ Most common inflammatory arthritis in M > 40yo ○ Often has triggers: alcohol, red meat, seafood lab/imaging: ○ Blood Tests: High uric acid levels- joint dysfunction due to uric acid crystals in the joints (“Hyperuricemia”) ○ RI/US: (NOT XRAY!) Uric acid crystal deposits in joints ○ Other: Arthrocentesis (a procedure where a doctor uses a needle to take fluid out of a joint.) (synovial fluid + uric acid) Alcohol is the worst enemy of the gout.... Water is my best friend... SLE: Systemic Lupus Erythematosus Disease Course: usually flare ups and remissions Multiple systems affected: cardio/pulm, integumentary, MSK/NEURO, blood, renal, immune, Signs/Sxs: ○ Skin lesions (up to 85%) ○ Muscle pain and/or Joint pain (up to 95%) ○ “Butterfly rash” (malar rash) (about 1/3) On the face; reddening in the shape of butterfly Education, counseling, physical therapy? - not sure about efficacy of PT, possible to treat impairments but not the disease process Polymyalgia Rheumatica (“PMR”) MOI/Onset: ○ Could appear quickly, worse in mornings Signs/Sxs: ○ NO JOINT SWELLING! ○ MUSCLE PAIN ○ Widespread aching, stiffness (shoulders, thighs, neck, low back) ○ Trouble lifting arms > shoulder height ○ Myalgia - muscle; not jOINT If You Suspect Rheumatic Disease: PT exam→ ○ Undiagnosed rheum disease? → refer to PCP or rheumatologist ○ Diagnosed rheum disease→ multidisciplinary management Has this patient been diagnosed with rheum?  ○ If been diagnosed→ they are most likely already being seen by team Not our job to diagnose, but be aware of the sequelae We are screening for these disease To prevent more serious consequences of disease→ refer even if it is a treat and refer PT Treatment & Rheumatological Disease If we do treat someone with rheumatic disease→ Stage 1: ○ Treat Pain & Inflammation ○ rest, ice Stage 2: ○ restore as much healthy functional motion as possible ○ Mobilization (ROM exercises, isometrics → prevent atrophy and loss of ROM) Stage 3: ○ Restore Strength ○ (Ther ex: low weight/high rep → progress to low rep/high weight) Stage 4: ○ Restore Function (AROM or AAROM t/o day at joints for nutrition, lubrication, and prevent organ dysfunction OA vs. RA Differential Diagnosis and Relevance to PT Practice Differences between OA and RA What is the cause of their joint stiffness? ○ stiffness can happen in both OA a lot more common than RA Significant portion of adults will suffer from OA at some point of their life Increasing age = risk factor for OA Osteoarthritis ○ 9.7% in sample of U.S. adults have OA ○ Leading cause of disability in older adults Rheumatoid Arthritis ○ 4.2% in sample of U.S. adults have RA Differential Dx: OA VS. RA Clinical Signs/Symptoms ○ Rheumatoid Arthritis More systemic and MANY joints affected Bilateral/Symmetric Joints: Fingers, hands, wrists PIPs, MCPs  (less common DIPs) Maybe: elbow, feet/ankles, knee, shoulder ○ Osteoarthritis More localized joint destruction and inflammatory process FEW-er joints affected Could be Unilateral or Bilateral Nodes, swelling Joints: KNEE, hip, shoulder, facets, 1st CMC, 1st MTP, DIPs, PIPs, (less common MCPs) Weight bearing joints take the brunt of this pathology Can affect joints in fingers, but more common in distal digital joints Lab Tests & Imaging ○ For Osteoarthritis Blood Tests: Negative Antibody Tests Normal CRP, ESR X-Ray/MRI: May or may not have Reduced joint space, osteophytes, sclerosis Could have Nodes (Bouchard’s -PIP, Heberden’s at DIPs)→ part of sequelae of osteophyte formation Not systemic and not an autoimmune disease Key trifecta usually present in OA suggestive of joint damage = joint space narrowing, sclerosis, Osteophytes or bone formation at those joint surfaces due to the increased forces at the joint interface Imaging example 1: Imaging: Example #2 Imaging example: #3 OA - Decreased joint space and RA OA - heberden (DIPs) and osteophytes at DIP Decreased joint space and bouchard's (PIPs) nodes osteophytes; Ulnar drift at MCPs Osteoarthritis Key Signs and Symptoms Demographics: ○ Males > Females (if < 50yo) - so younger males ○ Females > Males (If> 50yo) - so older females ○ > 50 - 60 yo MOI/Onset: ○ Gradual/insidious onset, progressive Disease Signs/Sxs: ○ Joints: uniarticular or polyarticular, common in hip, knee, shoulder, 1st MCP, 1st MTP ○ Later in Disease: nodules, joint deformities ○ Systemic: NONE Systemic symptoms should be absent and their presence should cause investigation into other pathologies. Treatments: ○ Meds: “DMOADs,Tyleonol, NSAIDs, ○ PT Treatment: AROM, Modalities for pain control, AD Rx ○ Low risk medications to control pain and inflammation ○ Injections may help with pain control for more severe disease; corticosteroid injections, hyaluronic acid injections→ mixed evidence Can have primary or secondary OA ○ Primary Don't know what causes it ○ Secondary Trauma or disease at the joint that initiates destructive process ○ As chondrocytes die→ imbalance where catabolism takes over Osteoarthritis : Risk Factors ○ *Age = single biggest risk factor for OA ○ Susceptibility Local risk factors Muscle strength, Muscle imbalances Physical activity Wrong movements ○ Trauma can predispose Occupation Joint injury, Joint alignment Body length bone inequality Systemic risk factor  Diet, obesity ○ predisposition/ Increased risk of OA Non modifiable risk factors Age Gender Genetics Ethnicity- blacks more affected Systemic risk factors Obesity Bone metabolism Pathophysiology of OA Either primary or secondary oA Articular cartilage damage can happen early within disease process ○ Damage to cartilage→ inflammatory cascade→ proinflammatory cytokines→ influx of macrophages, neutrophils→ destruction and dysfunction of joint ○ As these proinflammatory cells enter cartilage or synovium→ more destruction, chondrocyte death→ more catabolism than anabolism of tissues→ acceleration of breakdown ○ Contributing factor of damage from molecular patterns ○ Interleukins, inflammatory cells CPR for Hip Osteoarthritis Diagnosis 1. Pain AROM hip flexion 2. Pain AROM hip extension 3. PROM hip IR 60% of those with arthritis demonstrate psychological yellow flags > 60% of those with arthritis have never been instructed in exercise or physical therapy 50% of adults with heart disease have arthritis Children can develop arthritis Arthritis has no known cure 1 in 5 adults in the United States have arthritis; Arthritis is the leading cause of disability in the United States There are >100 forms of arthritis 1. This type of arthritis is the leading systemic autoimmune disease characterized by bilateral inflammation and extra-articular involvement. ○ Other facts/features include: ○ may be caused by tobacco  ○ typically begins in small peripheral synovial joints joints→progresses to larger more proximal joints if left untreated ○ advanced stages cause destructive and debilitating joint damage ○ ulnar drift of the digits and 'Z' deformity of the thumb hinder functional independence ○ early diagnosis is difficult due to no available pathognomonic laboratory test ○ the rate of heritability is 40-60% ○ prevalence is 2-3x greater in women than men ○ answer= Rheumatoid arthritis (RA) 2. This type of arthritis (picture) is a rare, "short-term" form of arthritis that occurs after a throat, digestive, urinary, or genital bacterial infection. ○ symptoms typically resolve within 3 -12 months ○ high tendency to recur after a new infection or stress ○ typical onset occurs between 20 - 50 years of age ○ Other facts/features include: joint pain and stiffness, especially in the knees, ankles, feet stomach pain and diarrhea increased frequency and discomfort with urination lower back and buttock pain ○ Answer: Reactive Arthritis (Reiter's Syndrome) 3. this type of arthritis characteristically demonstrates symmetrical pain and stiffness predominantly within the shoulders, but may also be experienced within the neck and hip. Other facts/features include: ○ rapid onset of symptoms may last from 1-14 days ○ symptoms are commonly worse in the morning and/or after rest/inactivity ○ pain and stiffness after activity lasts > 45 minutes ○ palpation commonly provokes diffuse pain without localization of a specific structure ○ 50% of patients will experience systemic symptoms of fatigue, malaise, weight loss, and/or low-grade fever ○ this type of arthritis does not lead to joint erosions ○ inflammation of the subacromial/subdeltoid bursa, long-head biceps tendon, RTC tendon, and/or glenohumeral synovium may accompany complaints ○ prevalence is higher in women > 50 years of age ○ Answer = Polymyalgia Rheumatica Complications of PMR ○ Giant cell arteritis ○ Adverse effects of corticosteroids ○ Depression  ○ Loss of mobility and independence ○ Aortic aneurysm 4. This type of arthritis is a multi-system disease with no specific medical test that can diagnose it. (imaging picture) Other facts/features include: ○ is a non-erosive polyarthritis that can affect any joint ○ pain in small joints of the hands and feet are most common ○ mild disease may have mucocutaneous involvement only ○ severe disease may have multiorgan involvement and failure ○ 50% of cases involve the heart (myocardial injury, effusion, fibrosis, circulatory impairments) ○ associated with significant risk of morbidity and mortality ○ women are 10x at greater risk than men ○ 90% of those diagnosed are women of childbearing age ○ Answer = Systemic Lupus Erythematosus (SLE) 5. This type of arthritis is one of the most common causes of chronic inflammatory arthritis in the United States. (foot imaging) Other facts/features include: ○ the most manageable form of arthritis ○ gaining weight (obesity) during adulthood increases risk ○ commonly affected by diet ○ acute flare-ups (>2 / year) are likely and are difficult to treat ○ caused by deposition of crystals in joints, soft tissues, and bones ○ associated with hypertension, kidney disease, diabetes ○ Renal and kidney problems, untreated high blood pressure may increase uric acid levels and trigger ○ Beer - higher risk, wine = lower risk ○ Answer - gout 6. This type of arthritis is characterized as an aggressive condition with the potential for significant morbidity and compromised quality of life. Other facts/features include: ○ immune-mediated inflammation of tendons, fascia, and joints ○ often accompanied by changes in skin ○ may affect organs, eyes, and blood vessels ○ associated with an increased risk of cardiovascular disease ○ Answer = Psoriatic Arthritis (PsA) 7. This type of arthritis commonly presents with complaints of stiffness and postural abnormalities before pain. Other facts/features include: (spine imaging) ○ presents insidiously and without obvious early symptoms  ○ >80% experience their first symptom before 30 years of age ○ pain is relieved with exercise but not rest ○ nocturnal pain relieved with frequent change of positions ○ cause remains largely unknown affecting the axial spine specifically ○ impaired mobility with pain in the back, buttock, and hip are common ○ answer= ankylosing spondylitis Effect of ankylosing spondylitis ○ Impaired vision Get immediate medical attention for pain in eyes and loss of vision in one or both eyes ○ Stooped shoulders ○ Tightness of chest Due to inflammation or fusing of chest bones ○ Bowel, bladder, sexual dysfunction Scars in bundle of nerves at spines base can interfere with control ○ Scaly skin Some people can develop psoriasis which causes red, scaly skin ○ Neck pain ○ Lung damage Can make it difficult to breathe or to fight off infections ○ Enlarged aorta ○ Heart health AS may increase risk of HTN, heart disease, or heart attacks ○ Exercise Exercise, swimming or water aerobics can help keep hips flexible ○ Pain and stiffness in feet What are common features shared by both osteoarthritis (OA) and rheumatoid arthritis (RA)? ○ morning stiffness upon awakening ○ more frequent in those overweight/obese ○ prevalence is higher in females than males ○ incidence increases with age" Generally speaking, the ratio OA and RA combined when comparing female:male is 3:1 ○ the reason for is is unclear ○ one hypothesis is that women generally utilize medical care more often than men, and thus, are accounted for more than men Which of the following facts about OA and RA are true? arthritis commonly leads to social withdrawal and an increased risk of cardiovascular events  arthritis causes patients to increase use of passive pain-coping strategies arthritis is correlated to impaired quality of sleep and psychological distress arthritis is a risk factor for developing mental health disorders later in life Depression is the #1 most common psychological yellow flag in those with OA and/or RA resulting in 1) fear-avoidance, 2) social withdrawal, 3) ruminating, 4) and low self-efficacy. 4 stages of Osteoarthritis Stage 1 Stage 2 Stage 3 Stage 4 minimal wear and tear minor joint degradation moderate joint significant joint (50-60% radiographs are radiographs show definite (25-50% cartilage loss) cartilage loss) predominantly unremarkable osteophyte formation and radiographs show, radiographs show severe but may show subtle possible joint space multiple osteophytes, sclerosis, large unilateral joint space narrowing definite joint space osteophytes, and evident narrowing narrowing, subchondral joint space narrowing sclerosis, and possible either unilaterally or bone deformity across the entire joint 4 stages of Rheumatoid arthritis ○ Stage 1 (Early stage) Mild pain, stiffness, tissue edema no destructive changes on radiographs ○ Stage 2 (Moderate stage) Clear swelling/redness, damaged bone, synovium inflamed  radiographic evidence of bone destruction and periarticular osteoporosis, but no joint deformity ○ Stage 3 (Severe stage) radiographic evidence of cartilage and bone destruction, periarticular osteoporosis, and joint deformity Stage 4 (End stage) bony or fibrous ankylosis, along with stage 3 features OA and RA have similar approaches for treatment; however, there are TWO approaches commonly emphasized when managing a patient with RA compared to OA. ○ Energy conservation techniques ○ Joint protection strategies In those with OA and RA, physical activity has been shown to improve 1) pain severity 2) improved mobility 3) improved strength 4) improved function 5) lower stress 5 great exercises for people with arthritis ○ Moderate activity one of the best ways to ease pain, increase mobility ○ Water walking or water exercise, walking, cycling, pilates, yoga, tai chi, social sport activities- shuffleboard or bounce ball What therapeutic approaches are/are NOT advised for arthritis caused by rheumatic disease? ○ Taping techniques ○ Laser - heat to already warm area ○ Dry needling - don't wanna puncture the skin- due to already inflammatory response- poses risk of infection ○ TENS - not enough evidence for tens and taping What clinical sign/symptom may be used to help determine if a patient is beyond stage 2 for either OA or RA? ○ Crepitus- OA, pannus - RA; both are grinding sounds Pannus - rubbing or grating of synovial tissue proliferation Crepitus - crunching/creaking sound of articular surfaces ○ Sounds from synovial joints are common and not always a sign of pathology.  ○ Cracking sounds: Cavitation - collapse of a pre-existing bubble (outdated terminology) Tribonucleation - opposing surfaces resist separation until a critical point - causes a drop in synovial pressure (modern terminology) What type of arthritis is shown within this picture ○ Unable to tell ○ The hand image demonstrates both Heberden's (DIP) nodes and Bouchard's (PIP) nodes. ○ These terms are predominantly diagnostic for OA but have been used to describe the same enlarged appearance of a joint in those with RA. ○ Technically speaking a "node" is a firm-hard bony enlargement. ○ The term "nodule" is more descriptive of a firm-springy lump of swelling. ○ Therefore, a "node" is more descriptive of OA while a "nodule" is more descriptive of RA. ○ Palpating the node itself in OA is unlikely to be painful while palpating the nodule in RA is typically tender. What are primary What are primary The arrows in this image The arrows in this image are radiographic findings radiographic findings are pointing to what pointing to what finding indicative of osteoarthritis? indicative of rheumatoid finding associated with associated with arthritis? arthritis? arthritis? red= subchondral sclerosis red= soft tissue swelling Osteopenia Subchondral cyst Blue = osteophytes Blue = osteopenia Green = asymmetric joint Green = symmetrical space narrowing joint space narrowing Is this osteoarthritis or rheumatoid Does this radiograph show OA or RA? Does this radiograph show OA or arthritis? and why? And what aspect of the ABCs helps RA? And why? with your clinical hypothesis? Rheumatoid arthritis...periarticular Osteoarthritis - cartilage Rheumatoid arthritis...erosion swelling Right GH photo Does this radiograph show OA or Does this radiograph show Is this osteoarthritis or rheumatoid RA? And what aspect of the ABCs osteoarthritis or rheumatoid arthritis? and why? (hand imaging) helps with your clinical hypothesis? arthritis? And why? (knee) Rheumatoid - soft tissue Osteoarthritis - osteophytes Rheumatoid arthritis...erosion Swelling around tibia and femur A 59-year-old female patient presents with complaints of bilateral hand and shoulder pain and swelling after engaging in a swimming routine. She expresses frustration as these symptoms have seemed to "come and go" over the past 5-6 months.  She reports a previous history of shoulder dislocation with repair and multiple hand injuries while playing college volleyball. She states she was recently discharged from the hospital secondary to having her appendix removed after a diagnosis of appendicitis. Based on this information alone, which condition is most likely? ○ Rheumatoid arthritis ○ Although reactive arthritis typically occurs after a preceding infection, such as appendicitis, the fact that a patient's complaints are bilateral in the hands and shoulders is not common to reactive arthritis. ○ Additionally, reactive arthritis is more common in men and the ages of 20-50. ○ The past history of shoulder injury following participation in a specific activity may suggest OA, but the bilateral complaints do not correspond with this. ○ Additionally, she indicates the likelihood of acute flare ups with moments of remission. A 65-year-old patient presents with joint pain and stiffness primarily in his right knee and hip. He has worked in construction his entire life. Upon examination, the patient exhibits hard-bony enlargements at the distal joints of his fingers. Although these do not cause pain he reports his fingers do feel stiff at times. The patient reports occasional pain in his right big toe that resolves relatively quickly with rest. Which condition is most likely? ○ Osteoarthritis A 50-year-old female patient presents with a history of morning stiffness lasting more than one hour and joint pain affecting her wrists and hands. She reports experiencing intermittent pain for ~2 months, often exacerbated by activity. Upon examination, the patient demonstrates decreased range of motion, joint effusion, and tenderness with palpation. She also has a history of smoking, psoriasis, and occasional eye irritation. Which condition is most likely? ○ Rheumatoid arthritis While RA is suggested by the symptoms and findings, the additional history of smoking makes the differential diagnosis of RA the most important consideration. PT Med Screening Lumbar Spine “Best Practices” for Acute Onset LBP Neuro testing if radiating symptoms Judicious use of Imaging (only use if suspect serious pathology) Medications, and Surgery Encourage Early return to work and activities Assess psychosocial factors Patient education that emphasizes strength of spine, pain science, favorable prognosis for most LBP, suggest active coping strategies Screen for red flags Notes:  ○ Chronic > 3 months ○ Stay away from wording that suggests harm or fear, try not to talk about imaging findings ○ Imaging often overprescribed and often overused in LBP Inappropriate Use of Imaging in LBP MRI often ordered inappropriately in cases of LBP WITHOUT RED FLAGS ○ 43% of MRI ordered in one sample with LBP were inappropriate Imaging may be appropriate IF: ○ Red flags are present OR ○ If a patient is unresponsive to 6 weeks of physical therapy treatment→ may refer or obtain imaging studies Asymptomatic Imaging Findings are VERY COMMON in the lumbar spine! ○ Imaging can show different degenerative changes without pain ○ Do not overly rely on imaging studies You are NOT your x ray What are “Red Flags”? “Red Flags are signs and symptoms that raise the suspicion of serious spinal pathology” How Good are “Red Flags”? ○ Critique of Red Flags as Screening Tool for Serious Spinal Pathology ○ Red flags = not necessarily valid to rule out a diagnosis (Poor – LR) CPGs do not provide help with clinical decision making (High # Red Flags) ○ Accuracy of Red Flags for screening in LBP = highly variable Night pain, hx of corticosteroid use, hx of cancer, palpation tenderness over SP, Bowel and bladder changes LBP screening is highly variable Is There a better way? Key clinical messages ○ There is a lack of evidence to support the informativeness of the majority of red flags commonly used in clinical practice ○ Few red flags, when used in isolation, are informative ○ Combinations of red flags demonstrate promise, but requires further validation and research to support those clusters of findings ○ Despite this, Red flags remain the best tools at the time for clinicians disposal to raise suspicion of serious spinal pathology when used within context of a thorough subjective patient hx and physical examination ○ Clinical suspicion is a highly recommended reason to refer or suspect red flag pathology→ must do comprehensive exam  ○ Clinicians should consider both the evidence to support red flags and the individual profile of the persons determinants of health to decide level of concern (index of suspicion) for presence of serious spinal pathology “Best Practices” for Acute Onset LBP Screen for red flags→ if none→recommend Early return to activity (work, social, recreation activities) as soon as they are able to Avoid bed rest Short term use of NSAIDs Education on favorable prognosis No overemphasis on pathology ○ If 1 or 2 red flags→ ○ If lots of red flags→ ○ Utilize multiple or clusters of red flags and perform through exam ○ If suspicious → can refer right away or engage in watchful waiting (reevaluate every time they come in) Lumbar spine screening ○ Best Evidence Recommendations: Utilize Multiple “Red Flags” Perform Thorough Exam (Subj + Obj) If Suspicious: “Watchful Wait” & ”Safety Net” Know referral pathways Clinical reasoning pathway: Decision tool 1. Asses level of concern Green light: ○ No concerning features→Low level of concern ○ Decision: begin a trial of therapy ○ Revise management if clinical features change unexpectedly ○ 1. Treat with conservative care PT ○ 2. If not responding in 4-6 weeks, reassess and possible referral Yellow light: ○ Little to Few concerning features, but not enough to refer→Lowish level of concern ○ Decision: begin a trial of therapy ○ Revise management if clinical features change unexpectedly ○ Monitor progress closely ○ 1. Trial with conservative care PT ○ 2. Take steps to initiate referral if needed ○ 3. Educate patients on signs/symptoms that would necessitate ER Orange light: ○ > few or some concerning features →Moderate to high level of concern  ○ Decision: urgent referral ○ Do not begin a trial of therapy ○ Further investigation of referral is warranted Red light: ○ some concerning features → High level of concern ○ Decision: emergency referral ○ Do not begin a trial of therapy 2. Clinical action ○ Treat vs refer 3. Identify appropriate referral path ○ Primary Care Physician ○ Neurologist ○ Orthopedist ○ Rheumatologist ○ Emergency Room Care Patient cases Case #1 ○ 36yo woman referred to your physical therapy clinic with a PT prescription from PCP for “Eval and Tx for low back and left leg pain”. ○ The pain in her left leg has been getting worse and is now radiating down to her shin/calf area below the knee. ○ She has also started to notice pain in her right buttock and leg. ○ She denies any bowel or bladder dysfunction, denies sexual dysfunction, and does not report paresthesia in the genital area. ○ She is able to walk back to the treatment room, with no apparent gait dysfunction. ○ Upon objective exam, her lower extremity dermatome, myotome, and reflex testing is insignificant, but she does have B positive SLR tests. ○ 1. Assess Level of Concern Yellow: few concerning features Bilateral sciatic→ may be suggestive of progressive neurological decline which can be a feature of cauda equina Concerning because its bilateral and traveling and progressing ○ 2. Treat or Refer? Treat, watchful wait and safety net ○ 3. Identify Appropriate Referral PCP, orthopedist, neurologist ○ No bowel/bladder changes, no saddle paresthesia No sexual dysfunction ○ No gait dysfunction & Clear neu